Provider Demographics
NPI:1790229367
Name:REMACLE, KELLIE NICOLE (RDH, BS)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:NICOLE
Last Name:REMACLE
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:NICOLE
Other - Last Name:SIMMONT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:CMR 427 BOX 2859
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09630-0029
Mailing Address - Country:US
Mailing Address - Phone:331-992-6411
Mailing Address - Fax:
Practice Address - Street 1:CMR 427 BOX 2859
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09630-0029
Practice Address - Country:US
Practice Address - Phone:331-992-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5069124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist